PTSD and Acute Stress Disorder

PTSD and Acute Stress Disorder Definition/Descriptions • Acute distress disorder usually begins within days of traumatic evens and lasts for upto a month Epidemiology • More common in females Aetiology • • • Triggers: - Sexual violence (most common trigger) - Physical violence - Accidents - Natura disasters - War - Diagnosis of severe disease - Witnessing death of another person Risk factors: - Physical comorbidities - Low SES - Child or adolescents at the time of trauma - Lack of social support - Female gender - Prior traumatic experience ➔ Including childhood experiencing and/or subsequent reminders - High perceived severity of traumatic event Common comorbidities - MDD - Substance use disorder - Somatic symptom disorder Clinical features • • • • • • • Instructive memories and/or dreams associated with the trauma Avoidance of reminders of traumatic event Mood and cognitive disturbances - E.g. dissociative amnesia, guilt, shame, isolation etc. Increase arousal - E.g. hypervigilance, violent outbursts Sleep disturbances Difficulty concentrating Distress or impairment in social, occupational or other important areas of functioning. Subtypes and variants • • PTSD with delayed expression - Meeting full criteria after 6 months of traumatic event PTSD with dissociative symptoms - Meets the criteria for PTSD and concomitantly experience symptoms of either derealisation or depersonalisation Diagnosis DSM-V PTSD TRAUMA A. T- traumatic experience - Direct exposure - Witnessing - Experiencing - Learning of an event B. R- re-experience event though memories, dreams, flashbacks, distress at exposure to cues that symbolise C. A- avoidance of stimuli associated with event D. M- mood and cognition changes e.g. memory of event, persistent negative emotions E. A- arousal and reactivity increased e.g. irritable outbursts, hypervilignece, reckless selfdestruction, tonic F. At least one month G. Clinically significant stress H. Exclude hallucinations ACUTE STRESS DISORDER A. Same as PTSD B. Nine or more of the following INSTRUSION SYMPTOMS - Recurrent, involuntary and instructive distressing memories of the traumatic event Recurrent distressing dreams related to event Dissociative reactions e.g. flashbacks Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolise events NEGATIVE MOOD - Persistent, inability to experience positive emotions e.g. inability to experience happiness, satisfaction or loving feelings DISSOCIATIVE SYMPTOMS - Altered sense of reality with one’s surrounding or oneself Inability to remember important aspects of traumatic events ➔ Usually due to dissociate amnesia and not due to other factors such as head injury or substance use AVOIDNACE SYMPTOMS - Efforts to avoid distressing memories, thoughts or feelings about or closely associated traumatic events. Efforts to avoid external reminders ➔ E.g. places and reminders AROUSAL SYMPTOMS - Sleep disturbances - Irritable behaviour - Hypervigilance - Problems with concentration - Exaggerated startle response C. Duration of the disturbance of criterion B is 3 days to 1 month D. Clinically significant distress or social impairment E. Not due to substance abuse or another medical condition Treatment and management • • • • Psychotherapy - Trauma focused therapy, CBT – exposure ➔ First line treatment for all patients with acute stress or PTSD Other recommended modalities - Prolonged exposure therapy - Cognitive processing therapy - Eye movement desensitisation and reprocessing (EDMR): ➔ Patient recalls traumatic images, sensations and emotional while undergoing bilateral hemispheric situation ➔ E.g. moving eyes from left to right Pharmacological: - Acute distress disorder ➔ There are no approved pharmacological treatments ➔ SSRIs may be considered ➔ If needed can use anti-depressants ➔ Beta blockers and alpha-adrenergic agents -> ,ay limit hyperarousal both initially and in long term management ➔ Consider mood stabilisers as needed PTSD - SSRIs or SNRIs ➔ Consider this for patients who are incomplete responders to decline to engage in or are unable to access trauma-focused therapy ➔ Options: sertraline, paroxetine, venlafaxine - Prazosin ➔ May considered for PTSD associated nightmares Key Info Benzodiazepines should be avoided due to the risk of misuse and the lack of evidence supporting therapeutic benefit